Physician Renewal From Burnout to Bonfire Marc Borenstein, MD, FACEP Professor and Chair Department of Emergency Medicine University of Missouri School

Physician RenewalPhysician RenewalFrom Burnout to BonfireFrom Burnout to Bonfire

Marc Borenstein, MD, FACEPMarc Borenstein, MD, FACEPProfessor and ChairProfessor and Chair

Department of Emergency MedicineDepartment of Emergency Medicine

University of Missouri School of MedicineUniversity of Missouri School of Medicine

Put Something Big at StakePut Something Big at Stake

Ways you could be listening to this Ways you could be listening to this presentationpresentation– Interesting/not interestingInteresting/not interesting– I already know this/I don’t know thisI already know this/I don’t know this– What really matters to me in my life nowWhat really matters to me in my life now

Definition of Physician Burnout Definition of Physician Burnout

Emotional exhaustionEmotional exhaustion DepersonalizationDepersonalization Low personal accomplishment: loss of Low personal accomplishment: loss of

drive for and sense of satisfaction from drive for and sense of satisfaction from workwork

Definition of Physician Burnout Definition of Physician Burnout

Differs Differs from depression in that burnout from depression in that burnout primarily affects an individual’s primarily affects an individual’s relationship to their workrelationship to their work

Deterioration of values, spirit, dignity, and Deterioration of values, spirit, dignity, and willwill

““Silent anguish of the healers”Silent anguish of the healers”

Epidemiology of BurnoutEpidemiology of Burnout

Early concerns for disproportionate levels Early concerns for disproportionate levels of career dissatisfactionof career dissatisfaction– ShiftworkShiftwork– Work intensity Work intensity – Lack of respect from medical colleaguesLack of respect from medical colleagues


Early concerns for disproportionate levels Early concerns for disproportionate levels of career dissatisfactionof career dissatisfaction– Lack of career self-determinationLack of career self-determination– Hourly worker, low compensationHourly worker, low compensation– Absence of long-term career growthAbsence of long-term career growth


ABEM longitudinal studyABEM longitudinal study– Response rate 94% (94), 84% (99), 76% Response rate 94% (94), 84% (99), 76%

(04)(04)– 77-80% EM met or exceeded expectations 77-80% EM met or exceeded expectations

for career satisfactionfor career satisfaction– 32% experienced burnout32% experienced burnout

Cydulka RK Korte R Ann Emerg Med 2008 51(6):714-22Cydulka RK Korte R Ann Emerg Med 2008 51(6):714-22


ACEP Scientific Assembly attendeesACEP Scientific Assembly attendees– 60% moderate to high burnout60% moderate to high burnout– Attrition 7.5% at 5 years and 25% at 10 Attrition 7.5% at 5 years and 25% at 10

yearsyears– Similar attrition rates in other specialtiesSimilar attrition rates in other specialties

Goldberg R Boss RW Goldberg R Boss RW et al et al Acad Emerg Med 1996 3(12):1156-64Acad Emerg Med 1996 3(12):1156-64


ACEP member surveyACEP member survey– 43% response rate43% response rate– 32% experienced at least one 32% experienced at least one

component of burnoutcomponent of burnout– Emotional exhaustion most oftenEmotional exhaustion most often– Anxiety/concern for bad outcomes Anxiety/concern for bad outcomes

Kuhn G Goldberg R Ann Emerg Med 2009 54:106-13Kuhn G Goldberg R Ann Emerg Med 2009 54:106-13


Mayo Clinic commentaryMayo Clinic commentary– 30 - 40% of physicians experience burnout30 - 40% of physicians experience burnout– ↑↑Error, Error, ↓↓empathy, empathy, ↑↑attrition, attrition, – Excessive workloads may increase furtherExcessive workloads may increase further

Dyrbye LN Shanfeldt TD JAMA 2011 305(19):2009-10Dyrbye LN Shanfeldt TD JAMA 2011 305(19):2009-10

Risk Factors for BurnoutRisk Factors for Burnout

Physician personality traitsPhysician personality traits– Obsessive - compulsiveObsessive - compulsive– Striving talents, pursuit of excellenceStriving talents, pursuit of excellence– EmpatheticEmpathetic– Repress emotionsRepress emotions

Risk Factors for Burnout Risk Factors for Burnout

↑↑PaperworkPaperwork ↓↓Financial reimbursementsFinancial reimbursements ↓↓Ancillary support Ancillary support ↓↓Resources to get non-clinical job(s) doneResources to get non-clinical job(s) done


↑↑Malpractice litigationMalpractice litigation ↑↑Compliance and accreditation regulationsCompliance and accreditation regulations ↑↑ED crowding/inadequate spaceED crowding/inadequate space Feeling of lack of support for EM and/or the Feeling of lack of support for EM and/or the

ED from colleagues and/or one’s institution ED from colleagues and/or one’s institution


↑↑Debt for residents and attendingsDebt for residents and attendings Difficult patients and absence of pre-Difficult patients and absence of pre-

existing patient/family relationshipsexisting patient/family relationships

Identifying Signs/Symptoms of Burnout Identifying Signs/Symptoms of Burnout

Cynicism, resignationCynicism, resignation AngerAnger IsolationIsolation Apathy, feeling numb or emotionlessApathy, feeling numb or emotionless


Work no longer enjoyable or funWork no longer enjoyable or fun No sense of humor or lightnessNo sense of humor or lightness Increasingly feeling no energy, tiredIncreasingly feeling no energy, tired Increased or new physical symptomsIncreased or new physical symptoms


Negative attitudes towards self, others, Negative attitudes towards self, others, patientspatients

New pattern of lateness, not completing New pattern of lateness, not completing workwork

Difficulty focusing at workDifficulty focusing at work

Identifying Signs/Symptoms of BurnoutIdentifying Signs/Symptoms of Burnout

Self-medicationSelf-medication– New day, same s**tNew day, same s**t– Same day, same s**tSame day, same s**t– Same old, same oldSame old, same old

Consequences of Burnout Consequences of Burnout

Medical errorMedical error DepressionDepression Substance and/or ETOH abuse/addictionSubstance and/or ETOH abuse/addiction


Partner/relationship discordPartner/relationship discord Boundary violationsBoundary violations Disruptive behaviorDisruptive behavior


Physician loss from the workplacePhysician loss from the workplace Diminished ED team Diminished ED team

effectiveness/productivityeffectiveness/productivity Loss of nursing and/or mid-level provider Loss of nursing and/or mid-level provider

staffstaff

From Burnout to BonfireFrom Burnout to Bonfire

RecognitionRecognition Work/career modificationWork/career modification Personal life changesPersonal life changes

Burnout Can be InsidiousBurnout Can be Insidious

You’re accomplishing your work and You’re accomplishing your work and getting things donegetting things done


Signs/symptomsSigns/symptoms– Feeling bored, tiredFeeling bored, tired– Not having much fun at workNot having much fun at work– Same old, same oldSame old, same old


The job is not a match for who you are, The job is not a match for who you are, your commitments, and what you can your commitments, and what you can contributecontribute– Is what you’re saying and doing in Is what you’re saying and doing in

alignment with your commitments and alignment with your commitments and values in life?values in life?

– If no in part or all, you’re at risk for If no in part or all, you’re at risk for burnoutburnout


SolutionsSolutions– Reclaim your childhood vision/missionReclaim your childhood vision/mission– Invent a new vision/missionInvent a new vision/mission– Take on a bigger gameTake on a bigger game– Consider taking a (careful) riskConsider taking a (careful) risk


The important thing is this: to be able at The important thing is this: to be able at

any moment to sacrifice what we are for any moment to sacrifice what we are for what we could becomewhat we could become

Charles DuboisCharles Dubois

Identifying BurnoutIdentifying Burnout

You’re working on a big, exciting project You’re working on a big, exciting project but have insufficient time to get the job but have insufficient time to get the job done done andand have a life outside work have a life outside work


You’re working on a big, exciting project You’re working on a big, exciting project but have insufficient time to get the job but have insufficient time to get the job done done withoutwithout a life outside work a life outside work


If the time you spend trying to do it all is If the time you spend trying to do it all is taken at the expense of your personal and taken at the expense of your personal and family lifefamily life– If yes in part or all, you’re at risk for If yes in part or all, you’re at risk for

burnoutburnout


SymptomsSymptoms– Feeling angryFeeling angry– I’m working harder than they areI’m working harder than they are– No one around here cares as much as I No one around here cares as much as I

dodo


SymptomsSymptoms– Tired/sleep deprived, working late at Tired/sleep deprived, working late at

home home – Stress with spouse, partner, familyStress with spouse, partner, family– I need a time management classI need a time management class

Self-monitoringSelf-monitoring

Trying to do it all yourself Trying to do it all yourself – May be compensation for a failure to May be compensation for a failure to

provide leadershipprovide leadership– Reliance on skills you already haveReliance on skills you already have– Staying within your comfort zoneStaying within your comfort zone

Self-monitoringSelf-monitoring

There is insufficient time for you to get There is insufficient time for you to get everything doneeverything done

All great projects require a teamAll great projects require a team Many great projects are not accomplished Many great projects are not accomplished

in a single lifetimein a single lifetime


SolutionsSolutions– Start from where you areStart from where you are– Invent a vision and a bold statementInvent a vision and a bold statement


SolutionsSolutions– Live your vision for the future in the Live your vision for the future in the

presentpresent– Communicate it……Everywhere!Communicate it……Everywhere!– Be a leader for your life and yourselfBe a leader for your life and yourself


SolutionsSolutions– Get a coachGet a coach– Build a teamBuild a team

What is Vision?What is Vision?

Future basedFuture based Seeing the possibility for something to Seeing the possibility for something to

emergeemerge Not predicted by past performance or Not predicted by past performance or

historyhistory

What is Vision?What is Vision?

Not defined or determined by Not defined or determined by circumstancescircumstances

Invented, createdInvented, created Exists in languageExists in language

I’ll Believe It When I See ItI’ll Believe It When I See It

What you What you already knowalready know about yourself, the about yourself, the world, and your past is in the way of world, and your past is in the way of seeing what’s present and discovering seeing what’s present and discovering anything newanything new

I’ll Believe It When I See ItI’ll Believe It When I See It

The real voyage of discovery consists not The real voyage of discovery consists not in seeking new landscapes but in having in seeking new landscapes but in having new eyesnew eyes

Marcel ProustMarcel Proust

Be a Leader for Your LifeBe a Leader for Your Life

Being and living your vision and Being and living your vision and commitment in the present commitment in the present

Having your actions, behaviors, and Having your actions, behaviors, and communication informed by your vision communication informed by your vision and commitmentand commitment

Be a Leader for Your LifeBe a Leader for Your Life

Creating, communicating, and sustaining Creating, communicating, and sustaining purposeful context consistent with your purposeful context consistent with your vision and your commitmentvision and your commitment

Why Be a Leader for Your Life?Why Be a Leader for Your Life?

You have a powerful commitmentYou have a powerful commitment Your voice and contribution matterYour voice and contribution matter

Why Be a Leader for Your Life?Why Be a Leader for Your Life?

Leadership galvanizes a team to Leadership galvanizes a team to accomplish a job beyond what can be accomplish a job beyond what can be achieved by the individualachieved by the individual

Leadership creates the leverage needed to Leadership creates the leverage needed to move the worldmove the world

The Power of LeverageThe Power of Leverage

1 EM physician provides care to 3000 pts/yr1 EM physician provides care to 3000 pts/yr Graduate 10 EM residents/yr = 30,000 ptsGraduate 10 EM residents/yr = 30,000 pts 30 year career/graduate = 900,000 pts30 year career/graduate = 900,000 pts 10 year RPD career = 9,000,000 pts10 year RPD career = 9,000,000 pts

The Power of LeverageThe Power of Leverage

Never doubt that a small, group of Never doubt that a small, group of thoughtful, committed citizens can change thoughtful, committed citizens can change the world. Indeed, it is the only thing that the world. Indeed, it is the only thing that ever has ever has

Margaret MeadMargaret Mead

The Bonfire Challenge The Bonfire Challenge

Discipline to articulate and sustain a vision Discipline to articulate and sustain a vision and sense of purposeand sense of purpose

New and/or expanded non-intellectual New and/or expanded non-intellectual skills and responsibilityskills and responsibility

The Bonfire ChallengeThe Bonfire Challenge

Effective and disciplined communicationEffective and disciplined communication– Ownership of outcomes and the Ownership of outcomes and the

experience of othersexperience of others– Creative v. descriptive languageCreative v. descriptive language


1:1: Willingness to take ownershipWillingness to take ownership 2:2: Creating the future through languageCreating the future through language 3:3: Prioritizing choices and taking actionPrioritizing choices and taking action 4:4: Thinking from abundance Thinking from abundance


5:5: Mining for the goldMining for the gold 6:6: Listening for the vision in what other’s Listening for the vision in what other’s

saysay 7: Embracing change7: Embracing change 8:8: Incorporating renewalIncorporating renewal 9: Seeking the inner journey9: Seeking the inner journey

Self-awarenessSelf-awareness

ConfidenceConfidence– Comfortable with divergent thinking, Comfortable with divergent thinking,

ambiguityambiguity– Able to consider other points of viewAble to consider other points of view

Accurate, realistic self-viewAccurate, realistic self-view– Thirst for constructive critiqueThirst for constructive critique

Self-awarenessSelf-awareness

HumilityHumility Candor, without self-significanceCandor, without self-significance

– Self-deprecating sense of humorSelf-deprecating sense of humor GratefulnessGratefulness The ability to create empowering contextThe ability to create empowering context

– Turn down the volume on negative Turn down the volume on negative thoughts thoughts

Self-regulationSelf-regulation

ReflectiveReflective– Not impulsive, reactive or emotionally Not impulsive, reactive or emotionally

drivendriven– Invites and considers all points of view Invites and considers all points of view

before taking actionbefore taking action FlexibleFlexible

Self-regulationSelf-regulation

Keeping one’s wordKeeping one’s word– Creates trustworthinessCreates trustworthiness– Builds integrityBuilds integrity

EmpathyEmpathy

Cultural sensitivityCultural sensitivity Appreciates and invites diversityAppreciates and invites diversity Drives service to othersDrives service to others

– Patient satisfactionPatient satisfaction Attraction/retention of talentAttraction/retention of talent

Social SkillsSocial Skills

Talent for finding common groundTalent for finding common ground Team-buildingTeam-building Leading changeLeading change Creating new and strengthening existing Creating new and strengthening existing

relationshipsrelationships– ““Schmoozing”Schmoozing”

Social SkillsSocial Skills

AffabilityAffability Communication excellenceCommunication excellence

MotivationMotivation

Innately driven to achieveInnately driven to achieve– Striving talentsStriving talents

AvailabilityAvailability Organizational commitmentOrganizational commitment

MotivationMotivation

Strongly optimisticStrongly optimistic TimelinessTimeliness Perseverance Perseverance The “Yes” mentalityThe “Yes” mentality

Time to Give UpTime to Give Up

Complaining, whiningComplaining, whining– Trashing the hospital, department, or Trashing the hospital, department, or

its leadership publiclyits leadership publicly Not taking ownership of a problemNot taking ownership of a problem

Time to Give UpTime to Give Up

Being argumentative, stubbornBeing argumentative, stubborn Engaging in gossipEngaging in gossip Comparing yourself or others to othersComparing yourself or others to others

Start From Where You Are Start From Where You Are Right NowRight Now

Invent a purposeful context for what you Invent a purposeful context for what you are already doingare already doing

Create a vision that articulates that Create a vision that articulates that purposeful context for you and for otherspurposeful context for you and for others

Start From Where You Are Start From Where You Are Right Now Right Now

Be sure your vision is in alignment with Be sure your vision is in alignment with your ED and institutional valuesyour ED and institutional values

Create a bold statementCreate a bold statement

Pick Two Areas of Your LifePick Two Areas of Your Life

Where to lookWhere to look– Where are you putting up with Where are you putting up with

something or someonesomething or someone– An area that looks hopelessAn area that looks hopeless– An area where you feel stuck, trappedAn area where you feel stuck, trapped– ““This is never going to change”This is never going to change”

Pick Two Areas of Your LifePick Two Areas of Your Life

Where to lookWhere to look– It’s them, or him, or her!It’s them, or him, or her!– An area or person where you used to An area or person where you used to

have a feeling of affinityhave a feeling of affinity– Sense of humor gone in this areaSense of humor gone in this area– An area where it’s very significantAn area where it’s very significant

Qualities of a Purposeful ContextQualities of a Purposeful Context

Must excite Must excite you you InclusiveInclusive Leave others with the possibility of Leave others with the possibility of

participation in and contribution to participation in and contribution to something bigger than the individualsomething bigger than the individual

Why Invent a Purposeful Context?Why Invent a Purposeful Context?

The story of the stone cuttersThe story of the stone cutters

Creating a Vision for Your LifeCreating a Vision for Your Life

To provide To provide dignitydignity, , compassioncompassion and and enhance the enhance the well-beingwell-being of each and of each and every personevery person

Creating a Vision for Your LifeCreating a Vision for Your Life

To honor the To honor the dignitydignity of the of the human spirithuman spirit ans have people leave with an experience ans have people leave with an experience of of being valuedbeing valued

Creating a Vision for LifeCreating a Vision for Life

The possibility of the workplace as a The possibility of the workplace as a healinghealing environment that enhances the environment that enhances the well-beingwell-being of of peoplepeople

One Possible Vision Statement for LifeOne Possible Vision Statement for Life

To create a Emergency Department that To create a Emergency Department that will serve as a model for what’s will serve as a model for what’s possiblepossible for people: a for people: a safe havensafe haven where where extraordinary extraordinary emergency care is emergency care is delivered with delivered with compassioncompassion, , timelinesstimeliness, , and a driving sense of and a driving sense of honoring the honoring the individualindividual

From the Creed of NBIMCFrom the Creed of NBIMC

Personal attention notable for its warmth Personal attention notable for its warmth and sincerity and inspired by a and sincerity and inspired by a sympathetic recognition of the human sympathetic recognition of the human element is the powerful but gentle element is the powerful but gentle handmaiden of science employed by handmaiden of science employed by doctors, nurses, and attendants at Beth doctors, nurses, and attendants at Beth Israel Hospital. Patients are people, not Israel Hospital. Patients are people, not cases at this hospital….they are men, cases at this hospital….they are men, women, and children, human beings, and women, and children, human beings, and are treated as suchare treated as such

From the Creed of NBIMCFrom the Creed of NBIMC

The value of the human touch as a power The value of the human touch as a power for healing is never lost sight of at Beth for healing is never lost sight of at Beth Israel HospitalIsrael Hospital

The Value of a Bold StatementThe Value of a Bold Statement

Bold statementBold statement– A non-linear future not predicted by the A non-linear future not predicted by the

pastpast– Simple, clearSimple, clear– Immediately communicates to allImmediately communicates to all


Bold statementsBold statements– NASANASA– Coca-ColaCoca-Cola


Putting Columbia on the map of academic Putting Columbia on the map of academic EMEM

Leaving a legacy of extraordinary Leaving a legacy of extraordinary emergency medical care for Missouri and emergency medical care for Missouri and beyond for generations to come beyond for generations to come

Practical TipsPractical Tips

Schedule everything you intend to doSchedule everything you intend to do– Schedule time for yourself, family, and Schedule time for yourself, family, and

friendsfriends– Frequently check your schedule with Frequently check your schedule with

your familyyour family Head, heart, body = Total well-beingHead, heart, body = Total well-being

– Schedule time for the mind, soul, and Schedule time for the mind, soul, and physical physical


Create an empowering context for some of Create an empowering context for some of your time at workyour time at work– Health fairsHealth fairs– Community educationCommunity education– CommitteesCommittees– ED and non-ED conferencesED and non-ED conferences


Know the rules for the game at workKnow the rules for the game at work Play the game at work by the rulesPlay the game at work by the rules Know the outcomes that define winningKnow the outcomes that define winning Know the scoreKnow the score

Practical Tips Practical Tips

Learn to say “no” Learn to say “no” – Empower and trust others to get the job Empower and trust others to get the job

donedone And “let go”And “let go”

– Annual inventory of projectsAnnual inventory of projects– Give away the ones that no longer excite Give away the ones that no longer excite

you, create income, or forward your you, create income, or forward your careercareer

Practical Tips Practical Tips

Make requestsMake requests– Let people know that you need helpLet people know that you need help

Communicate breakdowns earlyCommunicate breakdowns early Know what’s expected of youKnow what’s expected of you

In Conclusion: Burn BrightlyIn Conclusion: Burn Brightly

I’ve never seen anyone burnout from I’ve never seen anyone burnout from beingbeing

on fire on fire

Marc BorensteinMarc Borenstein


This is the true joy of life, the being used This is the true joy of life, the being used for a purpose recognized by yourself as a for a purpose recognized by yourself as a mighty one; the being a force of nature mighty one; the being a force of nature instead of a feverish little clod of ailments instead of a feverish little clod of ailments and grievances complaining that the world and grievances complaining that the world will not devote itself to making you happy. will not devote itself to making you happy.

I am of the opinion that my life belongs to I am of the opinion that my life belongs to the whole community and as long as I can the whole community and as long as I can live, it is live, it is


my privilege to do for it whatever I can.my privilege to do for it whatever I can.

I want to be thoroughly used up when I I want to be thoroughly used up when I die….Life is no brief candle to me. It is a die….Life is no brief candle to me. It is a sort of splendid torch which I have got hold sort of splendid torch which I have got hold of for the moment, and I want to make it of for the moment, and I want to make it burn as brightly as possible before handing burn as brightly as possible before handing it on to the next generation.it on to the next generation.

George Bernard ShawGeorge Bernard Shaw

Documents

Physician Renewal From Burnout to Bonfire Marc Borenstein, MD, FACEP Professor and Chair Department of Emergency Medicine University of Missouri School